Digital aid for talking more about death and dying: incorporating advance care planning to integrated care management tools

Introduction: Governments put health-system strengthening as priority. They particularly strive for person-centred health-systems. Integrated Care is seen as the way forward to achieve this. To improve patient experience and health outcomes, healthcare should be organised ‘horizontally’ around the patient and should be ‘vertically’ integrating services in various levels and settings. The Queen Elisabeth Rehabilitation hospital (KEI), encompassing 165 beds, wants to play a role in better healthcare for patients with specific and complex rehabilitation needs (cardiopulmonary, locomotor and neurological) and strives to centre its services on the needs of the patients, their families and the broader community. Methods and aim: In order to formulate a well-articulated strategic plan, KEI critically scrutinised its current work by studying available data. Since KEI developed a high level quality control management-plan, data from 2021 could be extracted from the patients records and analysed. Results: KEI, driven by a holistic vision on rehabilitation (medical, functional, social and psychological) intensively puts efforts in interdisciplinary team-integration (specialist-physicians, dietitians, occupational, speech- and language-, physiotherapists, psychologists, nurses, assistant nurses) supported by electronical patient-records and grounded in patient-participation. Also preventive (mostly ambulatory) coaching is offered (e.g. smoking cessation, tackling malnutrition and obesity). Patients admitted to KEI in 2021 (n= 1215) were transferred from hospitals (9% university-hospitals/83% non-university), from home (7%) and from nursing-homes (1%). They are discharged towards home (74%), nursing-homes (11%) or back to a hospital (11%). After discharge, extensive ambulatory follow-up was conducted with 2178 ambulatory consultations. This means that KEI extensively collaborated and exchanged information with stakeholders in the region: regional hospitals, primary care, nursing-homes. To fulfil its supra-regional task, KEI ...